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L APPLICATION FOR PERMITS SAN JOAQUIN .LOCAL HEALTH DISTRICT i 1601 E. HAZEL T ON AVE., STOCKTON, CA -Telephone (209) 466-6781 ` PERMIT EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.-This application is made incompliance with San-Joaquin County Ordinance No.549 for sewage or No. 1862 for,well/pump and the Rules and Regulations of the San Joaquin Local Health District. _ E City Address' � � 7//Z. � f Loft Size]^n PM Owner's NameE-�� !®AC - Address Z �/ Y ES 6 (N Le Phone Contractor Address License No. Phone YPE OF WELL/PUMP: NEW WELL ❑, WELL REPLACEMENT ❑- DESTRUCTION ❑ M PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PRO M AR CONSTRUCTION SPECIFICATIONS ❑ Industrial . ❑ Open Bottom ❑ M Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications F'1 Public F1 Other ❑ Delta epth of Grout Seal Type of Grout _ I I Irrigation- ".Appr, Depth I I Eastern Su ce Seal Installed by _ Repair Work Done ❑, Type of ump H.P. Stpt4 Work Done_ Well Destruction ❑ Well Diameter ` Sealing Material ltop 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (:I 'REPAIR/ADDITION) I DESTRUCTION (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence Commercial_/ Other Number of living units- Numb f bedrooms Character of soil to a or of 3 feet: B I Water table depth r SEPTIC TANK Type/Mfg i Capacity" G No. Compartments PKG. TREATMENT PLT. ❑ i ` Method of Disposal Distance to nearest: d WellFoundation Property;Line - LEACHING:LINE ❑ No. & Length of lines Total length/size v FILTER BED ❑ Distance to nearest: Well r Foundation Property Line 1. SEEPAGE PITS I I *Depth' '� Size _ Number SUMPS a.-- -w»•-❑" Distance to nearest. Well Foundation ~~Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and -rules and regulations of the San Joaquin Local.Health Di§trict. / Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not,,( employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature!!�u certifies the following: "I certify that in the performance of the'work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The ape• m t call or all r it ins ctions. Complete drawing on evers s• Cp� ZSigned X Tie Date: 7 Jf o FOR DEPARTMENT USE LY Application Accepted by Date 9 0 O Area Pit or Grout Inspection by (� Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi- 369-3621 ❑ Manteca 823-71N ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. +.EH1241REV.tinsl 4- EH td-28 �( ` 9-zo=o3'MILpnef hake keln 17�e dr& ,